Provider Demographics
NPI:1003534058
Name:WILD SAGE FAMILY THERAPY CENTER INC
Entity Type:Organization
Organization Name:WILD SAGE FAMILY THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:661-220-9226
Mailing Address - Street 1:190 SIERRA CT STE A322
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7607
Mailing Address - Country:US
Mailing Address - Phone:661-220-9226
Mailing Address - Fax:661-208-3998
Practice Address - Street 1:190 SIERRA CT STE A322
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7607
Practice Address - Country:US
Practice Address - Phone:661-220-9226
Practice Address - Fax:661-208-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty